On-site experience of a project to increase access to diagnosis and treatment of Chagas disease in high-risk endemic areas of Colombia.

Colombia has one of the largest burdens of Chagas disease globally, with about 438,000 people affected according to 2015 estimates. Despite this, < 1% of the population has had access to diagnosis and treatment. A patient-centered roadmap for Chagas disease was developed from 2015 onwards to address access barriers and increase diagnostic and therapeutic coverage and was implemented in five municipalities where Chagas disease is endemic. The mean number of people tested per year increased from 37 before the project to 262 following implementation, and the average days between medical order and diagnostic confirmation results decreased from 258 to 19. The mean days from diagnostic confirmation to treatment initiation decreased from 354 before the project to 135 after implementation. The 5,654 people tested included 3,467 women of childbearing age. The prevalence of T. cruzi infection was 11.5%, and thus far 266 people have received antitrypanosomal treatment. Collaborative creation and implementation of a patient-centered roadmap can address access barriers in specific contexts, helping to reduce the invisibility and burden of this neglected disease.

Interventions to bring comprehensive care to people with Chagas disease: Experiences in Bolivia, Argentina and Colombia.

Chagas disease (CD) affects over six million people and is a leading cause of heart failure in the Americas. Few are able to access diagnosis and treatment for CD, resulting in a missed opportunity to prevent morbimortality. Integration of testing and treatment with the primary healthcare level is a key step in ensuring affected people receive timely antitrypansomal therapy, which increasing evidence shows can prevent chronic complications from the disease and halt congenital transmission. This article describes three collaborative projects focused on increasing access to testing and treatment for CD through primary healthcare facilities in Bolivia, Argentina, and Colombia.

Comparative evaluation of immunoassays to improve access to diagnosis for Chagas disease in Colombia.

OBJECTIVE: Chagas disease affects over six million people, but less than 1% are diagnosed and treated. Complicated diagnostic processes are a major barrier. Colombia's previous diagnostic algorithm, using in-house tests, was difficult to scale up, creating significant access barriers for patients. A new algorithm using commercially manufactured immunoassays would potentially improve access, but these tests' performance in Colombian patients with Chagas disease is not well known. METHODS: We assessed seven commercially available assays. Samples (n=501), 93.8% originating from Colombia, were characterized as positive or negative based on standard procedure at the National Reference Laboratory. Performance characteristics were calculated for individual assays and hypothetical test pairings, then compared to the existing algorithm. RESULTS: Five of seven assays exhibited sensitivity >98% while six showed specificity >97%. A total antigen ELISA paired with a recombinant assay provided similar performance to the current diagnostic process. Six of six assays tested proved capable of detecting different Trypanosoma cruzi genetic lineages. CONCLUSIONS: The study indicated that several commercial assays accurately detect T. cruzi infection in Colombian patients. A simplified testing process with two commercial assays could perform comparably to the previous process, reducing cost and accessibility barriers and facilitating national scale-up.

Geospatial-temporal distribution of Tegumentary Leishmaniasis in Colombia (2007-2016).

BACKGROUND: Tegumentary Leishmaniasis (TL) is a neglected disease with worldwide distribution and considered a public health problem, especially in Latin America. In Colombia, the governmental epidemiological surveillance system (SIVIGILA) is responsible for collecting information on the presentation of cases of TL from each of the municipalities and departments. In absence of a study compiling and analyzing currently available metadata of TL in Colombia, this study describes the geospatial-temporal distribution of TL and identifies the regions of the country on which prevention measures should be established in order to control the disease. METHODOLOGY/PRINCIPAL FINDINGS: This is an exploratory descriptive analysis of the distribution of TL in Colombia. Information was collected on new cases of the disease during the years 2007-2016 from the Colombian reporting system (SIVIGILA). Incidence calculations were made based on population estimates by departments and biogeographical regions. Time evolution is shown in biennial maps. A 10-year series was analyzed, showing that the Amazon region is the most affected in terms of incidence, while the Andean region has the highest number of cases with a high variability among the departments that make it up. In those departments where there is a greater reported diversity of vector species, a large number of cases was observed. CONCLUSIONS/SIGNIFICANCE: Transmission dynamics of TL in Colombia in the past 10 years have been variable, with a greater concentration of cases in the central and southern departments. The present study contributes to improve the understanding of the patterns of distribution of TL in Colombia and can be a basis for future studies of impact evaluation of Health policies in the country and the region.

First Colombian consensus on congenital Chagas and clinical approach for women of child-bearing age diagnosed with Chagas / Primer consenso colombiano sobre Chagas congénito y orientación clínica a mujeres en edad fértil con diagnóstico de Chagas

Congenital transmission of Chagas disease has not been extensively studied in Colombia, and there are no standardized processes in the health system regarding the specific diagnosis, treatment and follow-up of this disease. To generate recommendations on congenital Chagas disease and Chagas in women of childbearing age in Colombia, a consensus of experts was developed. An extensive literature search through the Medline database was carried out using the MeSH terms: «Chagas disease/congenital¼, «prevention and control¼, «diagnosis¼, «therapeutics¼ and «pregnancy¼. Appropriate abstracts were selected and the full texts were analyzed. The relevant information was synthesized, classified, and organized into tables and figures and was presented to a panel of experts, which was composed of 30 professionals from various fields. Based on the Delphi methodology, three rounds of consultation were conducted. The first and second rounds were based on electronic questionnaires that measured the level of consensus of each question among the participants. The third round was based on a face-to-face discussion focusing on those questions without consensus in the previous consultations. The evidence was adapted to national circumstances on a case-by-case basis, and the content the final document was approved. These recommendations are proposed for use in routine medical practice by health professionals in Colombia.

La transmisión congénita de la enfermedad de Chagas ha sido poco estudiada en Colombia y existen pocos procedimientos rutinarios en el sistema de salud para el manejo de esta enfermedad. Por ello se desarrolló un consenso de expertos dirigido a generar recomendaciones de diagnóstico y tratamiento de Chagas con- génito y orientación a mujeres en edad fértil. Con ese propósito se realizó una búsqueda extensiva de la literatura, empleando una combinación de términos Mes (Chagas, Chagas congénito, prevención, control, diagnóstico, tratamiento y embarazo) para reflejar el estado del arte en cada tema de interés. Después de ello, se leyeron los resúmenes y aquellos seleccionados para análisis del texto completo. La literatura relevante se sintetizo, clasifico y organizo en tablas y se presentó al panel de expertos, el cual estaba constituido por 30 profesionales en diferentes áreas. Mediante la metodología Delphi se realizaron 2 rondas de cuestionarios virtuales y una reunión presencial en los cuales se evaluaron los niveles de acuerdo entre los participantes. Los puntos con falta de consenso durante las 2 rondas virtuales se expusieron durante las mesas de discusión en la ronda presencial. La evidencia utilizada se adaptó a las particularidades nacionales según el caso y se aprobó el contenido del documento final. Se propone que estas recomendaciones sean usadas por profesionales de la salud en Colombia.

Modelling historical changes in the force-of-infection of Chagas disease to inform control and elimination programmes: application in Colombia.

BACKGROUND: WHO's 2020 milestones for Chagas disease include having all endemic Latin American countries certified with no intradomiciliary Trypanosoma cruzi transmission, and infected patients under care. Evaluating the variation in historical exposure to infection is crucial for assessing progress and for understanding the priorities to achieve these milestones. METHODS: Focusing on Colombia, all the available age-structured serological surveys (undertaken between 1995 and 2014) were searched and compiled. A total of 109 serosurveys were found, comprising 83 742 individuals from rural (indigenous and non-indigenous) and urban settings in 14 (out of 32) administrative units (departments). Estimates of the force-of-infection (FoI) were obtained by fitting and comparing three catalytic models using Bayesian methods to reconstruct temporal and spatial patterns over the course of three decades (between 1984 and 2014). RESULTS: Significant downward changes in the FoI were identified over the course of the three decades, and in some specific locations the predicted current seroprevalence in children aged 0-5 years is <1%. However, pronounced heterogeneity exists within departments, especially between indigenous, rural and urban settings, with the former exhibiting the highest FoI (up to 66 new infections/1000 people susceptible/year). The FoI in most of the indigenous settings remain unchanged during the three decades investigated. Current prevalence in adults in these 15 departments varies between 10% and 90% depending on the dynamics of historical exposure. CONCLUSIONS: Assessing progress towards the control of Chagas disease requires quantifying the impact of historical exposure on current age-specific prevalence at subnational level. In Colombia, despite the evident progress, there is a marked heterogeneity indicating that in some areas the vector control interventions have not been effective, hindering the possibility of achieving interruption by 2020. A substantial burden of chronic cases remains even in locations where serological criteria for transmission interruption may have been achieved, therefore still demanding diagnosis and treatment interventions.

Transmission scenarios of major vector-borne diseases in Colombia, 1990-2016.

Introducción. Las enfermedades transmitidas por vectores representan más de 17 % de todas las enfermedades infecciosas y causan anualmente un millón de defunciones a nivel mundial. En Colombia, la malaria, el dengue, la enfermedad de Chagas y las leishmaniasis son condiciones endemoepidémicas persistentes.Objetivo. Determinar el comportamiento epidemiológico de las enfermedades transmitidas por vectores en zonas urbanas y rurales de Colombia entre 1990 y 2016.Materiales y métodos. Se hizo un estudio descriptivo del comportamiento epidemiológico de las principales enfermedades transmitidas por vectores en zonas urbanas y rurales de Colombia entre 1990 y 2016, con la información proveniente de fuentes oficiales secundarias.Resultados. En el periodo estudiado se registraron 5'360.134 casos de enfermedades transmitidas por vectores, de los cuales 54,7 % fueron de malaria y 24,9 % de dengue. Estos casos concentraron el 80 % de la carga acumulada de casos de enfermedades transmitidas por vectores. Las medianas de las tasas de incidencia fueron 1.371 y 188 por 100.00 habitantes para malaria y dengue, respectivamente. Además, los casos de chikungunya fueron 774.831 desde su introducción en el 2014 y, los de Zika, 117.674 desde su aparición en 2015. En las zonas rurales predominaron las enfermedades parasitarias transmitidas por vectores como la malaria, las leishmaniasis y la enfermedad de Chagas. A nivel urbano, predominaron el dengue, el chikungunya y el Zika.Conclusiones. La transmisión en Colombia de estas enfermedades es persistente en las zonas urbanas y en las rurales, y de tipo endemoepidémico en los casos de malaria, dengue, leishmaniasis y enfermedad de Chagas. Dicha transmisión se ha dado de manera focalizada y con patrones variables de intensidad. Asimismo, se mantienen las condiciones que han favorecido la transmisión emergente de nuevas arbovirosis.

Multi-criteria decision analysis and spatial statistic: an approach to determining human vulnerability to vector transmission of Trypanosoma cruzi

BACKGROUND Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is a neglected human disease. It is endemic to the Americas and is estimated to have an economic impact, including lost productivity and disability, of 7 billion dollars per year on average. OBJECTIVES To assess vulnerability to vector-borne transmission of T. cruzi in domiciliary environments within an area undergoing domiciliary vector interruption of T. cruzi in Colombia. METHODS Multi-criteria decision analysis [preference ranking method for enrichment evaluation (PROMETHEE) and geometrical analysis for interactive assistance (GAIA) methods] and spatial statistics were performed on data from a socio-environmental questionnaire and an entomological survey. In the construction of multi-criteria descriptors, decision-making processes and indicators of five determinants of the CD vector pathway were summarily defined, including: (1) house indicator (HI); (2) triatominae indicator (TI); (3) host/reservoir indicator (Ho/RoI); (4) ecotope indicator (EI); and (5) socio-cultural indicator (S-CI). FINDINGS Determination of vulnerability to CD is mostly influenced by TI, with 44.96% of the total weight in the model, while the lowest contribution was from S-CI, with 7.15%. The five indicators comprise 17 indices, and include 78 of the original 104 priority criteria and variables. The PROMETHEE and GAIA methods proved very efficient for prioritisation and quantitative categorisation of socio-environmental determinants and for better determining which criteria should be considered for interrupting the man-T. cruzi-vector relationship in endemic areas of the Americas. Through the analysis of spatial autocorrelation it is clear that there is a spatial dependence in establishing categories of vulnerability, therefore, the effect of neighbors' setting (border areas) on local values should be incorporated into disease management for establishing programs of surveillance and control of CD via vector. CONCLUSIONS The study model proposed here is flexible and can be adapted to various eco-epidemiological profiles and is suitable for focusing anti-T. cruzi serological surveillance programs in vulnerable human populations.

Multi-criteria decision analysis and spatial statistic: an approach to determining human vulnerability to vector transmission of Trypanosoma cruzi.

BACKGROUND: Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is a neglected human disease. It is endemic to the Americas and is estimated to have an economic impact, including lost productivity and disability, of 7 billion dollars per year on average. OBJECTIVES: To assess vulnerability to vector-borne transmission of T. cruzi in domiciliary environments within an area undergoing domiciliary vector interruption of T. cruzi in Colombia. METHODS: Multi-criteria decision analysis [preference ranking method for enrichment evaluation (PROMETHEE) and geometrical analysis for interactive assistance (GAIA) methods] and spatial statistics were performed on data from a socio-environmental questionnaire and an entomological survey. In the construction of multi-criteria descriptors, decision-making processes and indicators of five determinants of the CD vector pathway were summarily defined, including: (1) house indicator (HI); (2) triatominae indicator (TI); (3) host/reservoir indicator (Ho/RoI); (4) ecotope indicator (EI); and (5) socio-cultural indicator (S-CI). FINDINGS: Determination of vulnerability to CD is mostly influenced by TI, with 44.96% of the total weight in the model, while the lowest contribution was from S-CI, with 7.15%. The five indicators comprise 17 indices, and include 78 of the original 104 priority criteria and variables. The PROMETHEE and GAIA methods proved very efficient for prioritisation and quantitative categorisation of socio-environmental determinants and for better determining which criteria should be considered for interrupting the man-T. cruzi-vector relationship in endemic areas of the Americas. Through the analysis of spatial autocorrelation it is clear that there is a spatial dependence in establishing categories of vulnerability, therefore, the effect of neighbors' setting (border areas) on local values should be incorporated into disease management for establishing programs of surveillance and control of CD via vector. CONCLUSIONS: The study model proposed here is flexible and can be adapted to various eco-epidemiological profiles and is suitable for focusing anti-T. cruzi serological surveillance programs in vulnerable human populations.

Epidemiología de las principales enfermedades transmitidas por vectores en Colombia, 1990-2016 / Transmission scenarios of major vector-borne diseases in Colombia, 1990-2016

Resumen Introducción. Las enfermedades transmitidas por vectores representan más de 17 % de todas las enfermedades infecciosas y causan anualmente un millón de defunciones a nivel mundial. En Colombia, la malaria, el dengue, la enfermedad de Chagas y las leishmaniasis son condiciones endemoepidémicas persistentes. Objetivo. Determinar el comportamiento epidemiológico de las enfermedades transmitidas por vectores en zonas urbanas y rurales de Colombia entre 1990 y 2016. Materiales y métodos. Se hizo un estudio descriptivo del comportamiento epidemiológico de las principales enfermedades transmitidas por vectores en zonas urbanas y rurales de Colombia entre 1990 y 2016, con la información proveniente de fuentes oficiales secundarias. Resultados. En el periodo estudiado se registraron 5'360.134 casos de enfermedades transmitidas por vectores, de los cuales 54,7 % fueron de malaria y 24,9 % de dengue. Estos casos concentraron el 80 % de la carga acumulada de casos de enfermedades transmitidas por vectores. Las medianas de las tasas de incidencia fueron 1.371 y 188 por 100.00 habitantes para malaria y dengue, respectivamente. Además, los casos de chikungunya fueron 774.831 desde su introducción en el 2014 y, los de Zika, 117.674 desde su aparición en 2015. En las zonas rurales predominaron las enfermedades parasitarias transmitidas por vectores como la malaria, las leishmaniasis y la enfermedad de Chagas. A nivel urbano, predominaron el dengue, el chikungunya y el Zika. Conclusiones. La transmisión en Colombia de estas enfermedades es persistente en las zonas urbanas y en las rurales, y de tipo endemoepidémico en los casos de malaria, dengue, leishmaniasis y enfermedad de Chagas. Dicha transmisión se ha dado de manera focalizada y con patrones variables de intensidad. Asimismo, se mantienen las condiciones que han favorecido la transmisión emergente de nuevas arbovirosis.

Abstract Introduction: Vector-borne diseases account for more than 17% of all infectious diseases and annually they cause one million deaths worldwide. In Colombia, malaria, dengue, Chagas disease, and leishmaniasis are persistent endemo-epidemic events. Objective: To determine the behavior and transmission scenarios of vector-borne diseases in Colombia between 1990 and 2016. Materials and methods: We conducted a descriptive study on the epidemiological behavior of the main vector-borne diseases in Colombia between 1990 and 2016 based on information from official secondary sources. Results: During the study period, there were 5,360,144 cases of vector-borne diseases, 54.7% of which were due to malaria and 24.9% to dengue, accounting for 80% of the cumulative disease burden of vector-borne disease cases. The median incidence rates were 1,371 and 188 per 100,000 inhabitants for malaria and dengue, respectively. In addition, emerging events such as Chikungunya registered 774,831 cases since its introduction in 2014, while 117,674 Zika fever cases were reported since its emergence in 2015. In rural settings, parasitic vector-borne diseases such as malaria, leishmaniasis and Chagas disease predominated, while in urban scenarios dengue, chikungunya and Zika were predominant. Conclusions: Persistent epidemic and endemic transmission of vector-borne diseases in urban and rural settings in Colombia was observed mainly in the case of malaria, dengue, leishmaniasis and Chagas disease. Such transmission was focused and had variable intensity patterns. On the other hand, the conditions that have favored the emergence of new arboviruses persist.

Untangling the transmission dynamics of primary and secondary vectors of Trypanosoma cruzi in Colombia: parasite infection, feeding sources and discrete typing units.

BACKGROUND: Trypanosoma cruzi is the causative agent of Chagas disease. Due to its genetic diversity has been classified into six Discrete Typing Units (DTUs) in association with transmission cycles. In Colombia, natural T. cruzi infection has been detected in 15 triatomine species. There is scarce information regarding the infection rates, DTUs and feeding preferences of secondary vectors. Therefore, the aim of this study was to determine T. cruzi infection rates, parasite DTU, ecotopes, insect stages, geographical location and bug feeding preferences across six different triatomine species. METHODS: A total of 245 insects were collected in seven departments of Colombia. We conducted molecular detection and genotyping of T. cruzi with subsequent identification of food sources. The frequency of infection, DTUs, TcI genotypes and feeding sources were plotted across the six species studied. A logistic regression model risk was estimated with insects positive for T. cruzi according to demographic and eco-epidemiological characteristics. RESULTS: We collected 85 specimens of Panstrongylus geniculatus, 77 Rhodnius prolixus, 37 R. pallescens, 34 Triatoma maculata, 8 R. pictipes and 4 T. dimidiata. The overall T. cruzi infection rate was 61.2% and presented statistical associations with the departments Meta (OR: 2.65; 95% CI: 1.69-4.17) and Guajira (OR: 2.13; 95% CI: 1.16-3.94); peridomestic ecotope (OR: 2.52: 95% CI: 1.62-3.93); the vector species P. geniculatus (OR: 2.40; 95% CI: 1.51-3.82) and T. maculata (OR: 2.09; 95% CI: 1.02-4.29); females (OR: 2.05; 95% CI: 1.39-3.04) and feeding on opossum (OR: 3.15; 95% CI: 1.85-11.69) and human blood (OR: 1.55; 95% CI: 1.07-2.24). Regarding the DTUs, we observed TcI (67.3%), TcII (6.7%), TcIII (8.7%), TcIV (4.0%) and TcV (6.0%). Across the samples typed as TcI, we detected TcIDom (19%) and sylvatic TcI (75%). The frequencies of feeding sources were 59.4% (human blood); 11.2% (hen); 9.6% (bat); 5.6% (opossum); 5.1% (mouse); 4.1% (dog); 3.0% (rodent); 1.0% (armadillo); and 1.0% (cow). CONCLUSIONS: New scenarios of T. cruzi transmission caused by secondary and sylvatic vectors are considered. The findings of sylvatic DTUs from bugs collected in domestic and peridomestic ecotopes confirms the emerging transmission scenarios in Colombia.

[Strategy for determining a baseline in areas of vector interruption for Chagas disease]. / Estrategia para determinar la línea base en áreas de interrupción vectorial de la enfermedad de Chagas.

Objectives Present a strategy to determine the baseline in endemic areas in the process of vector interruption for Chagas disease (CHD). Methods A social and environmental questionnaire and an entomological survey evaluated the physical conditions of dwellings, the inhabitants' knowledge of CHD, the entomological triatomine indicators and the statistical relationship among these variables. Results Colonization and natural infection with Trypanosoma cruzi exist in Rhodnius prolixus, the principal vector of CHD in Colombia. Colonization was related to palm-thatched houses constructed with adobe or wattle and daub. The Panstrongylus geniculatus vector was found to be colonizing. Almost 50% of the surveyed population associated the term CHD with human disease and 37%, with triatomines. Conclusions R. prolixus can be considered to be the principal vector of T. cruzi in domestic environments and the process of interruption is feasible within the prioritized municipality. New studies are needed to verify the existence of wild populations of R. prolixus that could affect future stages of the process and demonstrate whether P. geniculatus is a factor in the transmission of T. cruzi. These scenarios can be made viable by including the inhabitants throughout the process, since they have been highly sensitive in vector detection inside their houses. The study design presented here can be adapted to other endemic areas of the Region of the Americas.

High-Resolution Molecular Typing of Trypanosoma cruzi in 2 Large Outbreaks of Acute Chagas Disease in Colombia.

Oral transmission of Trypanosoma cruzi has gained relevance because of its association with high morbidity and lethality rates. This transmission route is responsible for maintaining the infection of the parasite in sylvatic cycles, and human cases have been associated mainly with the consumption of food contaminated with triatomine feces or didelphid secretions. Several ecological changes allow the intrusion of sylvatic reservoirs and triatomines to the domestic environments with subsequent food contamination. Here, high-resolution molecular tools were used to detect and genotype T. cruzi across humans, reservoirs, and insect vectors in 2 acute outbreaks of presumptive oral transmission in eastern Colombia.

Estrategia para determinar la línea base en áreas de interrupción vectorial de la enfermedad de Chagas / Strategy for determining a baseline in areas of vector interruption for Chagas disease

RESUMEN Objetivos Presentar una estrategia para determinar la línea de base en áreas endémicas en el proceso de interrupción vectorial de la enfermedad de Chagas (ECh). Métodos Con un cuestionario socioambiental y una encuesta entomológica, se evaluaron las condiciones físicas de los domicilios, el conocimiento de los habitantes sobre la ECh, los indicadores entomológicos de triatominos y la relación estadística entre estas variables. Resultados Existe colonización e infección natural con Trypanosoma cruzi en Rhodnius prolixus, el principal vector de la ECh en Colombia. La colonización estuvo relacionada con casas de techos de hojas de palma y paredes de adobe o bahareque. Se encontró el vector Panstrongylus geniculatus con hábitos de colonización. Casi 50% de la población encuestada asociaba el término ECh con una enfermedad humana y 37%, con los triatominos. Conclusiones R. prolixus puede considerarse el principal vector de T. cruzi en ambientes domésticos y el proceso de interrupción vectorial es factible dentro del municipio priorizado. Se necesitan nuevos estudios que comprueben la existencia de poblaciones silvestres de R. prolixus que puedan afectar las etapas futuras del proceso y demostrar si hay una participación de P. geniculatus en la dinámica de transmisión de T. cruzi. Los anteriores escenarios pueden ser viabilizados con la inclusión de los habitantes en todo el proceso, ya que han sido altamente sensibles en la detección de vectores dentro de sus casas. El diseño del estudio aquí presentado puede ser adaptado en otras áreas endémicas de la Región de las Américas.

ABSTRACT Objectives Present a strategy to determine the baseline in endemic areas in the process of vector interruption for Chagas disease (CHD). Methods A social and environmental questionnaire and an entomological survey evaluated the physical conditions of dwellings, the inhabitants’ knowledge of CHD, the entomological triatomine indicators and the statistical relationship among these variables. Results Colonization and natural infection with Trypanosoma cruzi exist in Rhodnius prolixus, the principal vector of CHD in Colombia. Colonization was related to palm-thatched houses constructed with adobe or wattle and daub. The Panstrongylus geniculatus vector was found to be colonizing. Almost 50% of the surveyed population associated the term CHD with human disease and 37%, with triatomines. Conclusions R. prolixus can be considered to be the principal vector of T. cruzi in domestic environments and the process of interruption is feasible within the prioritized municipality. New studies are needed to verify the existence of wild populations of R. prolixus that could affect future stages of the process and demonstrate whether P. geniculatus is a factor in the transmission of T. cruzi. These scenarios can be made viable by including the inhabitants throughout the process, since they have been highly sensitive in vector detection inside their houses. The study design presented here can be adapted to other endemic areas of the Region of the Americas.

Primer consenso colombiano sobre Chagas congénito y orientación clínica a mujeres en edad fértil con diagnóstico de Chagas / First Colombian consensus on congenital Chagas and clinical approach to women of fertile age diagnosed with Chagas

La transmisión congénita de la enfermedad de Chagas ha sido poco estudiada en Colombia y existen pocos procedimientos rutinarios en el sistema de salud para el manejo de esta enfermedad. Por ello se desarrolló un consenso de expertos dirigido a generar recomendaciones de diagnóstico y tratamiento de Chagas congénito y orientación a mujeres en edad fértil. Con ese propósito se realizó una búsqueda extensiva de la literatura, empleando una combinación de términos MeSH (Chagas, Chagas congénito, prevención, control, diagnóstico, tratamiento y embarazo) para reflejar el estado del arte en cada tema de interés. Después de ello, se leyeron los resúmenes y aquellos seleccionados para análisis del texto completo. La literatura relevante se sintetizó, clasificó y organizó en tablas y se presentó al panel de expertos, el cual estaba constituido por 30 profesionales en diferentes áreas. Mediante la metodología Delphi se realizaron 2 rondas de cuestionarios virtuales y una reunión presencial en los cuales se evaluaron los niveles de acuerdo entre los participantes. Los puntos con falta de consenso durante las 2 rondas virtuales se expusieron durante las mesas de discusión en la ronda presencial. La evidencia utilizada se adaptó a las particularidades nacionales según el caso y se aprobó el contenido del documento final. Se propone que estas recomendaciones sean usadas por profesionales de la salud en Colombia.

Congenital transmission of Chagas disease has not been extensively studied in Colombia, and there are no standardized processes in the health system regarding the specific diagnosis, treatment and follow-up of this disease. In order to generate recommendations on congenital Chagas disease and Chagas in women of childbearing age in Colombia, a consensus of experts was developed. An extensive literature search through the Medline database was carried out using the MeSH terms: " Chagas disease/congenital " , " prevention and control " , " diagnosis " , " therapeutics " and " pregnancy " . Appropriate abstracts were selected and the full texts were analyzed. The relevant information was synthesized, classified, and organized into tables and figures and was presented to a panel of experts, which was composed of 30 professionals from various fields. Based on the Delphi methodology, three rounds of consultation were conducted. The first and second rounds were based on electronic questionnaires that measured the level of consensus of each question among the participants. The third round was based on a face-toface discussion focusing on those questions without consensus in the previous consultations. The evidence was adapted to national circumstances on a case-by-case basis, and the content the final document was approved. These recommendations are proposed for use in routine medical practice by health professionals in Colombia.

Respiratory disease and particulate air pollution in Santiago Chile: contribution of erosion particles from fine sediments.

Air pollution in Santiago is a serious problem every winter, causing thousands of cases of breathing problems within the population. With more than 6 million people and almost two million vehicles, this large city receives rainfall only during winters. Depending on the frequency of storms, statistics show that every time it rains, air quality improves for a couple of days, followed by extreme levels of air pollution. Current regulations focus mostly on PM10 and PM2.5, due to its strong influence on respiratory diseases. Though more than 50% of the ambient PM10s in Santiago is represented by soil particles, most of the efforts have been focused on the remaining 50%, i.e. particulate material originating from fossil and wood fuel combustion, among others. This document emphasizes the need for the creation of erosion/sediment control regulations in Chile, to decrease respiratory diseases on Chilean polluted cities.

Laparoscopic Nissen solo surgery using PMAT (first experience).

This article describes the use of a Postural Mechatronic Assistant Trainer (PMAT) in pediatric Nissen surgery. This mechatronic system enables users to establish the logistical considerations for solo surgery and determine the advantages this new tool offers for the autonomous handling of optics.

Tonatiuh II: assisting manipulator for laparoscopic surgery.

In this article we show the design of the Tonatiuh II robotic manipulator. This robotic assistant has an original electromechanical configuration and respects the laparoscope center of insertion as an invariant point for navigation in the work space. The manipulator went through several stages before reaching its final version. Surgical trials have shown the robot to be useful in the operating room and as a training assistant in specialty microsurgery.